Graduate medical education has undergone dramatic changes in the last decade. Surgical trainees and programs alike are now under increasing pressure to efficiently achieve and document competency in both skills acquisition and cognitive learning. These educational mandates are occurring simultaneous to national outcomes and patient safety initiatives. Simulation technology has emerged, as a reasonable expansion of modern medical education, to fit these seemingly dichotomous needs for training institutions. Existing training devices or simulators are low fidelity items generally comprised of a box with a piece of material sutured to the box. Such existing boxes also only teach a single task within a more complex multistep surgical procedure. In other words, such boxes do not reproduce the entire operation. Furthermore, such boxes do not replicate the intraoperative environment or the exact space limitations of the chest or abdominal cavity of a patient. Instead, the box may be empty. Moreover, such boxes do not provide a clear indication of relevant anatomy or the numerous anatomic pathologies that are common operative indications. Additionally, such boxes do not provide an opportunity to assess intraoperative decision-making specific to a complex operation, or the ability to assess an error in that decision-making process. Without relevant pathologic anatomy, size appropriate models, or an opportunity to assess intraoperative decision-making and error, improvements to surgical performance by surgeons may be difficult.
Pediatric surgery is a field particularly well suited to simulation technology. A number of the index procedures required for training are rare congenital anomalies. Further, the particular anatomy of the anomaly may vary widely. Esophageal atresia with or without a tracheoesophageal fistula (EA/TEF) is one such rare case with a number of different anatomic variations. In 1995, the mean number of EA/TEF repairs performed by a trainee in North America was 9.2 (range 2-20). By 2006, the mean number of repairs had dropped to 4.4 in the United States. With few opportunities for trainees to perform any EA/TEF repair, EA/TEF repair may not be feasibly taught to a high level of competence within a 2-year training period. Beyond the initial training period, practicing pediatric surgeons have even fewer opportunities to maintain or advance cognitive, technical and nontechnical skills for EA/TEF repair. With literature supporting an inverse relationship between case volume and surgical complications, relevant opportunities for deliberate practice and mastery learning are necessary to ensure optimal outcomes for infants and children.
Effective simulation models vary, according to the baseline skill level of the trainee. Box trainers focus on specific tasks, such as peg transfer and intracorporeal knot tying. These models are well suited for novice learners. However, advanced learners typically require high physical fidelity models, aiming to recreate the entire procedure, rather than just a single skill required during the procedure. In pediatric surgery, there are no validated procedural trainers for neonatal, infant or childhood surgical diseases.
Another rare congenital anomaly that requires surgical correction shortly after birth is diaphragmatic hernia (DH), which is a hole in a diaphragm that allows intestines to move into the chest cavity. The surgical repairs have historically been performed through a large abdominal incision. Newer surgical techniques allow the procedure to be performed using three small chest incisions (also known as thoracoscopic repair). The advantages with thoracoscopic repair include less scarring, less pain and faster recovery for children. However, a thoracoscopic repair in a newborn infant is challenging due to space limitations. The entire operation takes place inside a space the size of a chicken egg. Several studies on thoracoscopic DH repair show a higher recurrence rate, compared to the traditional repair. The higher recurrence is likely related to technical errors occurring during the thoracoscopic repair. High physical fidelity simulation would provide the opportunity to disseminate nationally the best practices for the performance of a thoracoscopic DH repair without a higher recurrence rate.
Duodenal atresia is another rare congenital anomaly that requires surgical repair shortly after birth. In this anomaly, the first part of the intestine (duodenum) is obstructed, preventing the infant from eating. Laparoscopic duodenal atresia repair is well described, but some authors have had higher complication rates than would otherwise be predicted for these infants. The complications were directly attributed to the learning curve of a difficult technical operation, and that with more experience, complication rates returned to an acceptable low baseline rate.
Additionally, Gastrostomy tube (GT) placement is a common procedure that is performed in infants and children who present with feeding failure secondary to prematurity, gastroesophageal reflux, primary or recurrent aspiration, and other indications. Placement of gastrostomy tubes in infants using a laparoscopic approach has been described as safe, efficacious, and may have a lower complication rate than percutaneous endoscopic gastrostomy. The U-stitch technique, is one of the most commonly used techniques for laparoscopic GT placement. Although laparoscopic GT placement is quickly learned and demonstrated, there are no pediatric GT placement simulators currently available in the market.
Studies have shown that simulation can be a valuable tool for training pediatric surgeons to perform a surgical procedure such as, for example, thoracoscopic repair of rare congenital anomalies. Previously evaluated simulators may require use of fetal bovine or porcine tissue blocks within the simulators. In some instances, real or biologic tissue blocks may be expensive and may not be readily available in some parts of the world.